31005 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 31005.g O O 'V1
r
' BUIL.DINGDIVISION APPLICATIONA'ERMIT PLUAIIIING-MECIIANICAT, �KJ 11
"U",ING PROJECT IDItNT IFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
2,a 3ocr .5Tet E-u S azezilc ew o. I mF:r2
OWNER'S NAME: PHONE: CONTRACTORS NAME: LICNO:
19 NIC CONTROL#
,RCHITECTENGINEER: LIC NO: ADDRESS. ❑
G 01101
CONTACT. PHONE: BUILDING PERMIT INFO
N y��IM ;n,-Q�aQ ❑ Consultant Few Paid"by Applicant(Initial) BLpG a?Cf PLUMB MECH
LICENSED COJ+NTRAMOR'S DECLARATION ICJ QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under pmvisinns of Chaper 9(commencing JOB DESCRIPTION
n%z with Section 7")of Division Sof the Husirrosund Profession,Code,and in license is
OO in full lirzue and clYcct, y PERMIT ISSUANCE RESIDENTIAL,
C,er" ❑SFDWL ❑KITCHEN REMODEL.
U�J License Class Lic.#
hzLL Date Contractor APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
D on ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
z O'er Z I understand my plans shall he used as public rete d, PANELS
O z 4 UP TO 200 AMPS MODIFICATION
[:. f-'W Licensed Pnsfcuinual ❑INTERIOR ❑CHIMNEY REPAIR
<SgRZ,...41 201.1000AMPS IMPROVEMENT
q4 C a 6 1 M1ereby aflimt OWN S C'^^''r mE he CommOor's License hw far the OVER laOAMPS ❑BATH R17MODEUREPAIR ❑DEMOLITION
x 36 U following reason.(Section 703 1.5,Business end Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
uF LLO{� which retryires a permit m Construct,ober,improve,J<mnlisIN,or repair any structure
prior In its issuance,it requires the all'from for such Penn lIn f le usignedsmtemenl SPECIAL CIRCUIT/MISC.
that he is licensed pursumvm the provisinnsof the Comment's license Law(Chapter 9
IC-7qC�0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INSL COMMERCIAL
a
that he is exempt therefrom and the basis for the alleged exemption,Any vindoors of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by my vpplicanl for a permit subjects the applicant to a civil penalty of POWER DEVICES
zzzrzed not more than rive hundred dollum(S5W1. NT FOOD SERVICE
O ❑Loa nwnerof the propcny,nr my employees with wages as"eir axle compensation, SWIMMING POOL ELECTRIC IM ROVEMENT.
willdmhework.antl the structure is not intended ur offered for sale(ScC.71W,Bvsi
p<ss OTHER
e4d1 and Professions Cale:The Connectors License Law Jens no,apply to an owner of UTUflFS-SWITCHES-FIXTURE,%
a 3 - property who builds or improves Merton,and who does such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RHSIDENTIAL ELECTR SQ PT.
sale.If.howevcn the hui III ng of improvement is.said within one year of completion,Inc SQ.IlLddLOQ,R 1' $/SQ.PI'.
ownerhuildr,Is 11 havcthe burden of proving that he did not build or i reprove for pur- IN' Fa
po fnele.
mee
r of the pmpeny,ora exclusively contracting with licensed contractors to TG
mnstmct the project(Sec.7614,Business and Professions Code:)The Conlmcnsrs Li. Q FEB 27 RECI®
cense Law does not apply to an owner of property who but ids or improves thereon,anJ TY, PLUMBING PERMIT FEE
who Crmmcls Porsn'h 'th ucnnvucmr(s)IlcenseJ_y�)u,•taks)Iy1te/�/,,'Is�/'�'f�/a
Orense l.aw. C A�j�,r lT1 /n PERMIT I A E 21 f�rf)f/jf I�rs) �I�AIo
Dae FFF CCC hu4rfw ALTER- &VENTW WALM(EA) L. G.///J''' _a VALUATION
WORKEB:SCOMPIiNSAT1ON DLCLARATION BACK I WP ';CI'.DEVICE
Ih eyaRrm aid,penallyrl perjury one of the fitllnwing declarations: v CV/V
❑I have and will maintain a Certificate of Consenuo self-insure for Worker's Cooper- DRAINS-F OOR, EEA, OND STORIES TYPECONSTRUCTION
cation,m provided for by Sermon 37M of the Labor Code,for"e Performance of the e�w V t m eyw
work for which Nis permit is issued. IXTUR- AP �) A ^ -pL KLV
❑I have and will maintain Workers Compensation Insurance,us nquircJ by Section 4 �' 1-'Rr
3700ofthoLabar Code,for the Performance of the work for which this permit is issued. GAS-PA.,Y. INC.40U .f3'IN OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are -
Carrier. Policy Na: - GAS-FA.SYSTEM-OVW; ) R +ng.•�q
CERTIFICATE OF EXEMPTION FROM WORKERS' `' 269-01- -"1(N�Q
COMPENSATION INSURANCE GRFASEANDUSTRI.WASTE I CEPTOR BUILDING DIVISION PCE%
(This section need not he completed lithe permit is throne hundred dollars($100) GRRASIi'I'RAP
or less.) PLANCHECK FEE
I verify that in the performance of the work for which this promil is issued,l shall
not employ my person in eny mannersnas mbceome subject 9.the Workers Crm SEWER-SANITARY-STORM EA.2W FT.
3 pen- ENERGY FEE
cation ant of Califnmin.Dem
O Applicnnt WATER IIIiATER WNENfELECfR GRADING FEE
rj NOTICE In APPLICAN'P IL after making this Ccoilb"m of Exemption,you should WATER SVS'TEMOREATING -
a ; become subject to the Worker's Compensatinn previsions of the Gans Code you must SOILS FEE
Lkl forthwith comply with such provisions or this permit shall he Jecmedevoked. WATER SERVICE
Q
sal. z
CONSTRUCTION LENDING AGENCY NEW RISIUENTIALPLMB. SQ.FT. PAID
1 hereby U work
thi lhenhereissued(Sec.30 lendingagency I.,the performance of _ Date Receipt#
I" the work for which Chili permit Is issued(Sec.3097.Civ.C.)
Lenders Name
TOTAL:
GAddressxs
FU Lenders Address
6s 1 certify that I have real this application and state that the above information is BUILDING FEE G
h correct.l agree to comply with all city and county oNinunces and sate laws relining to QTY. MECHANICAL PERMIT FEE
C)
building construction, heroby authaiacrposes.ntmlvca of this city reenter upon the SEISMIC FEE
abovo(We)agree
to
for indncrify n lacep es. - PERM IT ISSUANCE
(We)agree to save,indemmfy end keep hay in an the City ri Cmpenst against ELECTRIC PIiE
inconsequent ofth costa xsanit. may in any way accmeagainst and City .TER OR ADD TO MECIL PLUMBING FEE
nsegncnce of M1 Ing of Nis ,mit.
APP .COMPLY WITH AIleTINT AIR HANDLING UNITOO 10,000 CPM) MECHANICAL FEE
RCE T S.
Ile,
AIR HANDLING UNIT(OVER 10,(00CIrM) CONSTRUCTION TAX
Si mums Ca
nt/ mwcar Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEEH AHWUS MATERIALS DISCLOSURE
WII .m afumre building swcupvm score nr handle humNrns marerial HEATING UNIT(•I'O I000M BTU) ,
as delinW by the Cupertino Municipal Code,Chapter 9.12,and"c Health and Safety
Cade,Section 2553200HEATING UNIT(OVER 110,000 BTU)
❑Yes ❑No
VLNTIfAT10N FAN(SINGLE RFSID) PAID Dnte Receipt#
Will Cha of,coam it arca b Fal by the Bay
BOILER-BO 100,000BTU)
it District?
us air cnntwninums-as defined by the Pay Arca Air Quality Munagemenl 'TOTAL:
Dismct7
El Yes []No � BOILER-COMP(OVER 100,000 BTU)
(have tend" hat maerials rcquirtmenu under Chapter 6.95 of Ne Cali- AIR CONDITIONER ISSUANCE DATE
fomin f1 hh&S ale,Sscu ns 255113,25533 and 25534.I understand that if the NEW RESIDENTIAL MEClL SQ.FT.
b ng en recta smyrssryaslhbll on
cupam
of"e hie d acs ancy.
mer o e agent ate T ISSUED BY:
OFFICE